Epilepsy

During a seizure, stay calm, time it and protect the person from injury. Move hazards away, cushion the head and, when possible, turn the person gently onto one side. Do not hold them down, put anything in their mouth, or give food or water until fully alert. Call local emergency services if a seizure lasts longer than five minutes; another begins before recovery; breathing or waking is difficult; it is a first known seizure; serious injury occurs; it happens in water; or the person is pregnant or has diabetes and loses consciousness. Follow an existing individualized rescue plan if one is available.

What are seizures and epilepsy?

A seizure is a temporary episode caused by abnormal electrical activity in the brain. It may cause jerking, stiffening or a fall, but it can also appear as staring, altered sensation, unusual behaviour, brief confusion or loss of awareness. A seizure does not automatically mean epilepsy: fever, very low blood glucose, acute illness, intoxication or withdrawal can provoke an acute symptomatic seizure without an enduring tendency to recur.

The International League Against Epilepsy defines epilepsy through any of three routes: at least two unprovoked seizures more than 24 hours apart; one unprovoked seizure with a recurrence risk comparable to having had two; or diagnosis of an epilepsy syndrome. A specialist interprets these criteria for the individual.

Seizure and epilepsy types

The 2025 ILAE seizure classification has four main classes: focal, generalized, unknown whether focal or generalized, and unclassified. Focal seizures begin in networks on one side of the brain and may occur with preserved or impaired consciousness; some spread to become bilateral tonic-clonic seizures. Generalized seizures engage networks on both sides and include absence, generalized tonic-clonic, myoclonic and other types. Describing the sequence of what happened is often more useful than applying a label without evidence.

Epilepsy is also classified as focal, generalized, combined generalized and focal, or unknown, with a syndrome named when possible. This matters because the wrong medicine can worsen some seizure types.

Causes and triggers are different

Underlying causes may be structural, genetic, infectious, metabolic, immune or unknown. Examples include prior stroke or head injury, a developmental brain difference, a genetic syndrome, central nervous system infection, tumour or an immune condition. “Genetic” does not always mean inherited, and no cause is found for some people.

A trigger is something that makes a seizure more likely in a person who already has epilepsy. Missed medicine, sleep loss, fever, illness, stress, flashing light in photosensitive epilepsy, alcohol or substance use and withdrawal are possible examples, but triggers vary. Keeping a diary can reveal patterns without implying blame. Never test a suspected trigger deliberately.

Diagnosis after a suspected seizure

A first suspected seizure needs prompt medical assessment; NICE recommends urgent specialist review, ideally within two weeks. The account of the person and any witness is central. A safe phone video can help, but nobody should delay first aid or take a risk to record one. Assessment includes examination, medical and family history, medicines and substances, and possible cardiac or metabolic causes of a collapse.

An electroencephalogram (EEG) can support the diagnosis and classification, but a normal EEG does not rule out epilepsy. MRI is usually the preferred brain scan when imaging is indicated; CT is useful in selected urgent settings or when MRI cannot be done. Blood tests, ECG, genetic testing or other investigations are selected according to age and findings. Functional or dissociative seizures are real and deserve appropriate care but are not caused by epileptic electrical activity; some people have both conditions.

Treatment is individualized

Antiseizure medicine is the main treatment. Choice depends on seizure and epilepsy type, age, other health conditions, interactions, possible pregnancy, side effects, access and preference. Often one medicine is started and adjusted gradually. If seizures continue, diagnosis, classification and adherence should be reviewed before an additional or different treatment is chosen.

Take medicine as prescribed and discuss adverse effects, mood change or supply problems promptly. Do not stop suddenly: withdrawal can cause seizures or status epilepticus. After two seizure-free years, stopping may be considered only after an individualized recurrence-risk discussion, including driving and SUDEP. If agreed, reduction is gradual—usually over months and one medicine at a time under clinical supervision.

Some antiseizure medicines can harm a pregnancy. Valproate has important reproductive risks for female and male patients, and topiramate has pregnancy-related restrictions in some jurisdictions. Rules differ by country. Anyone who could become pregnant, is planning pregnancy, or whose partner may become pregnant should seek specialist advice before conception. Do not stop either medicine without urgent specialist guidance, because uncontrolled seizures can also be dangerous.

When seizures continue

Drug-resistant epilepsy is generally considered when two appropriate, tolerated medicine regimens have not produced sustained seizure freedom. Prompt tertiary epilepsy review can confirm the diagnosis and consider resective surgery—even when routine MRI is normal. For selected people, specialist options include a supervised ketogenic diet, vagus nerve stimulation or other devices. A ketogenic diet is a medical therapy with nutritional and metabolic risks, not a do-it-yourself wellness diet.

Safety, wellbeing and SUDEP

A care plan should address bathing and water safety, heights, cooking, sport, work or school, rescue medicine where appropriate, contraception and pregnancy, mental health and local driving law. Restrictions should match the person's seizure pattern rather than isolate them unnecessarily. Showering may be safer than bathing for someone with uncontrolled loss-of-consciousness seizures; swimming needs an informed companion and individualized advice.

Epilepsy is associated with injury, drowning, depression, anxiety, stigma and increased premature death. Sudden unexpected death in epilepsy (SUDEP) is uncommon but important to discuss openly. Risk is higher with uncontrolled generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures, especially at night. Taking medicine consistently, improving seizure control and reviewing individual night-time risks can reduce risk, although no measure removes it completely.

Outlook and continuing care

WHO estimates that up to 70% of people with epilepsy could become seizure-free with appropriate diagnosis and treatment. This population estimate is not a promise for one person: outcome varies with cause, syndrome, access to care, treatment response and other needs. Regular review should cover seizures, side effects, memory, mood, sleep, reproductive health and personal goals. People with ongoing seizures deserve specialist reassessment rather than blame.